EROTIC DISTRESS
Mail And Fax Order Form
*** CLICK YOUR
BROWSERS PRINT BUTTON FOR THIS FORM ***
Want To Go Back To EROTIC DISTRESS? CLICK HERE
MAILING INFORMATION:
Include your check or money order paying
for the term you wish to join, and mail to:
MaL Content Media 304 Main Avenue - Suite 250, Norwalk, CT 06851
Make all checks payable to: MaL Content Media, LLC
Money Order memberships will
be active within 24 hours of receipt of payment
Video Orders will be shipped withen 72 hours of payment
ALL Personal Checks must clear
the bank before your
membership will be activated, this may take up to 14 days.
FAXING INFORMATION:
Fax this completed form to the following number 203 - 849 - 1594
|
YOUR FULL
NAME:____________________________________________________________
STREET ADDRESS:___________________________________________________________
CITY:______________________ STATE:_____________________ ZIP CODE:_____________
COUNTRY:___________________________________________________________________
PHONE NUMBER:_____________________________________________________________
E-MAIL ADDRESS (required):________________________________________________
TOTAL AMOUNT YOU OWE (In US Currency) $_________________________________
VIDEO ORDERS
FATAL ERROR $34.85 (Post Paid - VHS)|
FATAL ERROR $39.,95 (Post Paid - PAL)
STALKED! $34.85 (Post Paid - VHS)|
STALKED! $39.,95 (Post Paid - PAL)
FORCED $34.85 (Post Paid - VHS)|
FORCED $39.,95 (Post Paid - PAL)
For Memberships Only - PLEASE CHOOSE THE TYPE OF MEMBERSHIP:
RECURRING or NON-RECURRING
One month = $14.95 - Three months = $44.00 - Six months = $80.00 - One Year = $160.00
CHOOSE A USER NAME:________________________________
(up to 8 letters/numbers)
CHOOSE A PASSWORD:________________________________
(up to 8 letters/numbers)
YOUR CREDIT CARD NUMBER (FOR FAX ONLY):__________________________________
YOUR CREDIT CARD'S EXPIRATION
DATE:__________________
YOUR SIGNATURE: __________________________________________________________
Certifying you are an adult and over 18 years old.
|